Attitudes Towards and Experiences with Economic Incentives for Engagement in HIV Care and Treatment: Qualitative Insights from a Randomized Trial in Kenya

Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways–differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients’ perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analyses revealed that incentives helped PLHIV prioritize care-seeking by alleviating transport barriers and food insecurity: “<i>I decided to forgo [work] and attend clinic […] the voucher relieved me</i>”. Patients who borrowed money for care-seeking reported feeling relieved from the burden of indebtedness to others: “<i>I borrow with confidence that I will pay after my appointment</i>.” Incentives fostered their autonomy, and enabled them to support others: “<i>I used the money to buy some clothes and Pampers for the children</i>.” Participants who were intrinsically motivated to engage in care (“<i>my life depends on the drugs</i>, <i>not the incentive</i>”), and those who mistrusted researchers, reported being less prompted by the incentive itself. For patients not already prioritizing care-seeking, incentives facilitated care engagement through alleviating transport costs, indebtedness and food insecurity, and also supported social role fulfillment. Conditional cash incentives may be an important cue to action to improve progression through the HIV treatment cascade, and contribute to better care retention.

越来越多的文献表明，条件性现金激励（conditional cash incentives, CCIs）对HIV护理保留具有异质性影响。该领域尚缺乏对激励措施以不同方式影响不同患者的原因的深入理解——这些差异可能源于作用机制中心理与社会因素的变异。深入理解患者对用于保留护理的CCIs的认知与体验，或许有助于阐明这些机制。我们开展了一项嵌入ADAPT-R试验（NCT#02338739）的定性研究，该试验是一项序贯多分配随机试验（sequential multiple assignment randomized trial, SMART），旨在评估经济激励措施对肯尼亚境内启动抗逆转录病毒治疗的艾滋病病毒感染者（persons living with HIV, PLHIV）保留HIV护理的支持效果。按时就诊的参与者每次可获得约4美元的激励金。2016年7月至2017年6月期间，我们对39名参与者进行了访谈，以探究其对基于护理参与的经济激励措施的态度与体验。分析结果显示，激励措施通过缓解交通障碍与粮食不安全问题，帮助PLHIV优先选择就医：“<i>我决定放弃[工作]去诊所……代金券让我松了口气</i>。”为就医而借钱的患者表示，他们从对他人的债务负担中解脱出来：“<i>我有信心借钱，因为我知道预约后可以偿还</i>。”激励措施增强了他们的自主性，并使他们能够支持他人：“<i>我用这笔钱给孩子们买了些衣服和帮宝适（Pampers）</i>。”那些出于内在动机参与护理的参与者（“<i>我的生命依赖药物，而非激励</i>”）以及不信任研究者的参与者表示，他们较少受到激励措施本身的推动。对于尚未优先考虑就医的患者，激励措施通过降低交通成本、缓解债务与粮食不安全问题促进了护理参与，同时也支持了社会角色的履行。条件性现金激励或许是推动HIV治疗流程进展、改善护理保留率的重要行动线索。